Universal Health Care Utilization Management
The Utilization Management Department is compromised of the following areas:
- Pre-service determination
- Concurrent Review, including hospitals and SNF's
- Case Management/Disease Management
The UM department normal business hours are Monday through Friday 8 a.m. to 5 p.m.
These hours are for routine pre-service and other utilization functions.
Telephone: 866-616-6398
Fax number: 866-420-4842 (pre-service determinations) or
800-889-6745
(concurrent review)
Web site: www.univhc.com
Clinical Criteria for UM Decisions:
UHC utilizes nationally recognized criteria to determine medical necessity and clinical
appropriateness. Criteria may also be developed by UHC based upon a review of literature
and government regulations in collaboration with the Medical Director. The Medical
Advisory Committee, consisting of local practicing physicians, approves all criteria
annually, or as indicated. Criteria utilized are consistent with clinical guidelines.
UHC adapts procedures for applying criteria to meet individual member needs and
local medical practice. The Provider Manual includes the criteria utilized. Practitioners
may also request the criteria from the UM Department. UHC’s Medical Director,
is available during normal business hours to discuss a denial case with the treating
or attending practitioner; and can be contacted by calling the UM department number
given above.
Case Management:
Providers are able to refer members to the UHC Case Management Program. The purpose
of this valuable resource is for nurse case managers to help members obtain access
to care/services and assist with the coordination of care. The UHC Case Management
Program is designed to ensure that health care resources are utilized in a timely,
cost effective manner to achieve optimal wellness for the member. Possible candidates
for enrollment in the UHC Case Management Program include, but are not limited to,
members with multiple chronic illnesses or multiple hospital admissions, members
with catastrophic illnesses or serious trauma, members with AIDS, members with organ
transplants, high-risk neonates or members needing specialty health care. To refer
a member to the UHC Case Management Program, please contact the Case Management
Department at 866-616-6398
Disease Management:
Providers are able to refer members to the UHC Disease Management Program. The purpose
of the Disease Management Program is to promote awareness of the disease process
and the medical management of selected diseases to members through education and
monitoring of their conditions. The goal of disease management is to increase the
member’s compliance with the medical management program and prevent complications.
The Disease Management Program is coordinated by experienced nurse case managers.
Nationally recognized educational materials are sent to members. The Disease Management
Program is available for members with a diagnosis of CHF, COPD, Diabetes and Pediatric
Asthma. To refer a member to the UHC Disease Management Program, please contact
the Disease Management Department at 866-616-6398.